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UNIFIED PROGRAM CONSOLIDATED FORM Q UNDERGROUNDSTORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORM N(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this ren and Sections I,II,RL IV,and IX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE [:] 8.UST REMOVAL 4306 DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - O - BUS ES3�d tT 6 Same I[L�ITY[JANE r D�B.A- g T ')e�S)� l L 3 BUSINES S t�1 \�1 10J CITY l04 IL TANK DESCRIPTION TANK TO# 432 TANK MANUFACTUftER 433 TANK CONFIGURATION: THIS TANK IS 4M Coni )� ❑I.A STAND-ALONETANK O ( LC 9l c2.ONE IN A COMPARTMENTED UNIT. LLVJJ lJ 5 �y (I m tae ore forwch wm ml in a,e,mit DATE UST IYET INSTALLED 435 TANK CAPA rrY IN GALLONS 636 NUMBER OF COMP,gRTMENTS IN THE UNIT 437 .TANK USE AND CONTENTS LL TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(bale Usaial) ❑ 5.EMERGENCY GENERATOR FUEL IHSC$25281.5(.)] ❑ 6.017HER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: P la.REGULAR UNLEADED ❑ 1..MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ LSINGLEWALL IT2.DOUBLEWALL 095.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL -,3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify) 444+ SECONDARY CONTAINMENT ❑ 1.STEEL W3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 f❑ 90.NONE ❑ 95.UNKNOWN C199.OTHER(Specify): "Sa OVERFILL PREVENTION 1.AUDIBLE$VISUAL ALARMS 2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE-WALLED 2.DOUBLE-WALLED [199,OTHER 460 SYSTEM TYPEI,PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR¢2636(aX3)] 4% PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 151 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE b 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING(rURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4444 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 4Mei VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 46491 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) a6ab 46961 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL C9 2.DOUBLE WALL 090.NONE 4641. RISER PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS Ll10.RIGID PLASTIC ❑ W.NONE U 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464a 461k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET R 3.STRIKER PLAT"OTTOM PROTECTOR NJ4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL El 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE W)a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ I0.RIGIDPLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT El 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with Iegal requirements APPLICANT SIGNATURE DATE ..470' APPLICANT NAME(prim) 401' APPLICANT TITLE JT_ / UPCF UST-B-I/2 Rev.(12/2007)